As you may have heard, the U.S. Secretary of State Hillary Clinton has been receiving treatment (blood thinners) for a blood clot identified between her brain and skull. This was picked up in a routine MRI scan, however, it is unclear quite what 'routine' means? Dr Marc Straus said “It’s a little bit odd that there would be a routine MRI unless she had symptoms. I suspect something led them to do the tests that we don’t know about.”

Reports say that a couple of weeks ago she had a fall, which was the result of a stomach virus she was suffering from. This fall then caused concussion and she may have complained about a headache or other symptoms.

There have been some voices who have said that this was just an excuse for Clinton to get out of standing in front of Congress to give testimony about a terror attack on the US mission in Benghazi, Libya. However, this is purely speculation.

She did have symptoms, like a persisting headache, so it wasn´t "routine", but according to the guidelines."Routine MRI" would be sth like French psychiatrist (and author) David Servan-Schreiber had when participating in a medical trial as a student. He was diagnosed with a malignant cerebral tumour without having any previous symptoms.

I gather she was "concussed" , so seems reasonable. How many of us would have adopted a wait and see policy if HC had been brought into A&E? Also the political pressures in the US for medical details to be in the public eye. I also had a problem recently with both ends projectile and small sips by mouth regime did not work. , going on to thready pulse etc.... Seems crazy to have to go to A&E for a bit of IV with risk of en route contamination of any vehicle and spreading infection. Much better if I could have been left a bag of saline and a giving set on the doorstep .... but better dead than self-treated ? I can quite see how HC would have wanted to esape the clutches of hospital attendance and then fell in haste to reach the loo. She has my sympathies .

I do agree with both, Carolin and respected Sken. Just to review the 'Concussion', ---

Concussions are usually injuries no one sees and,contrary to popular belief, don't show up on most magnetic resonance imaging (MRI) exams or CT scans. As a result, conventional CT or MRI scans of the brain are usually not needed where post-concussion signs or symptoms are mild and clear within a week to ten days. Concussions are typically associated with grossly normal structural neuroimaging studies in general. Routine MRI is, however, recommended in the cases where 1.Loss of consciousness (LOC)for more than a minute seconds (concussions may or may not involve LOC, with 90% of all concussions occurring without LOC), 2.Prolonged impairment of the conscious state, especially if there is any suggestion of a deteriorating level of consciousness, 3. Dramaticworsening of a headache, 4. Speech or language difficultiessuch as aphasia or dysarthria, poor enunciation, poor understanding of speech, impaired writing, impaired ability to read or to understand writing, inability to name objects (anomia), 4.Vision changessuch as reduced vision, decreased visual field, sudden vision loss, double vision (diplopia), 5.Neglect or inattention to the surroundingson one sideof the body, 6.Loss of coordination, or loss of fine motor control (ability to perform complex movements), 7. One-sided eyelid drooping, lack of sweating on one side of the face, and sinking of one eye into the socket, 8. Poor gag reflex, swallowing difficulty, and frequent choking, 9.Seizures,10.Worsening post-concussion signs or symptoms, or persistent symptom, longer than 7 to 10 days, like in the post-concussion syndrome.

A CT scan is thetest of choice to evaluate for the four types ofintracranial haemorrhage(subdural, epidural, intra-cerebral, or subarachnoid) bleeding in the brain, swelling of the brain during the first 24 to 48 hours after injury, or to detect a skull fracture because it is faster, more cost-effective, and easier to perform than an MRI.No test, however, currently available is sensitive and specific enough to diagnose all intra-cranial injuries. MRI is viewed as superior in detecting traumatic lesions of the brain,and does not expose patients to radiation, its use is recommended for assessing traumatic sport-related brain injuries, especially after the acute period.

No one does "routine MRI" even in US. So, I presume there were some symptoms that led to an MRI.

Just another curiosity: for the "regular" patient the imaging that would've been used would be CT. In this case I suspect that either they went directly to MRI because it has better resolution( although, some neuroradiologists prefer angio CT for some pathologies).Another possibility is that the MRI came after a CT in order to confirm findings and refute other findings that CT could have missed due to lower resolution.

There is no routine MRI however.

This led me to think about a silent killer we encounter in our practices. Cerebral aneurysms that cause sudden subarachnoid hemorrhage and if not diagnosed and embolised quickly can cause sudden death or significant handicap.

I haven't seen too many studies that estimated the prevalence of cerebral aneurysms in general populations. It is an interesting issue together with another potential killer- abdominal aortic aneurysm.

My question would be- if we want to diagnose silent occlusions of coronary arteries, cerebral and aortic aneurysms, occlusions of femaoral arteries , carotid artery stenosis and renal artery stenosis, isn't it time to develop an available modality to access the vasculature from certain age, especially if there are risk factors such as family history, smoking, obesity, diabetes, hypertension etc.? Just a thought. Today we do only cardiac CT. But even that is in debate.

No one does "routine MRI" even in US. So, I presume there were some symptoms that led to an MRI. Just another curiosity: for the "regular" patient the imaging that would've been used would be CT. In this case I suspect that either they went directly to MRI because it has better resolution( although, some neuroradiologists prefer angio CT for some pathologies).Another possibility is that the MRI came after a CT in order to confirm findings and refute other findings that CT could have missed due to lower resolution. There is no routine MRI however. This led me to think about a silent killer we encounter in our practices. Cerebral aneurysms that cause sudden subarachnoid hemorrhage and if not diagnosed and embolised quickly can cause sudden death or significant handicap. I haven't seen too many studies that estimated the prevalence of cerebral aneurysms in general populations. It is an interesting issue together with another potential killer- abdominal aortic aneurysm. My question would be- if we want to diagnose silent occlusions of coronary arteries, cerebral and aortic aneurysms, occlusions of femaoral arteries , carotid artery stenosis and renal artery stenosis, isn't it time to develop an available modality to access the vasculature from certain age, especially if there are risk factors such as family history, smoking, obesity, diabetes, hypertension etc.? Just a thought. Today we do only cardiac CT. But even that is in debate.Posted by yoram chaiter

Well said Yoram! I do agree with you in respect of a very important clinical point of detection of occlusions of coronary arteries, cerebral and aortic aneurysms, occlusions of femaoral arteries , carotid artery stenosis and renal artery stenosis, quite often missed, and are diagnosed only at some major cardiovascular event.

What if the story about the stomach virus was a cover up for the true reason for the fall.

Then the MRI would have made sense. Maybe they were actually looking for the reason for the fall, not checking on the results of the fall. Maybe there were those subtle symptoms that indicated a deeper problem but haven't been made public. Maybe they don't want the rest of the world to know that Hillary was having a brain problem, certainly not in her position. Maybe she was lucky to get such intense investigations before it became serious. The man or the woman in the street would not have got such attention. Maybe it is what government secrets you know, what political figures you've got some dirt on, and who you can make sorry they crossed you that makes the difference with the standard of medical care.

She is the Secretary of State for USA.That makes her a very important person. She may have had certain symptoms that warranted Investigations. The best is always reserved for them, in case anything is missed. After all the doctors did detect an extra dural haemorrhage.

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